The British HIV Association has issued new guildlines for HIV testing . (pdf) They are very nearly extremely sensible. But…
One in five of the people newly diagnosed with HIV in the UK last year were diagnosed with AIDS at the same time. That means they’d probably been walking around with HIV infection for eight or nine years without ever being tested. Thinking they were uninfected, they might have had more unprotected sex than they would have if they knew they had HIV. Certainly, they’ve got a higher chance of dying in the next two years than people who got diagnosed and put on treatment earlier on. So yes, we want to get more people tested sooner.
The thing is that we’ve got a pretty good idea who is most likely to be infected in Britain. Gay men and people who have come to the UK from sub-Saharan Africa. People who inject drugs. The people that all of those people have sex with, plus people who are having unprotected sex with lots of other people, and who are thus getting infected with other sexually transmitted infections. The new testing guidelines very specifically say that all of these people should be offered HIV testing, routinely, every time they come into contact with the health services. They’re listed in sections A and C in the bit of the guidelines that I’ve coped below. (One group not included is people in prison, even though prisons are one of the places where drug users are most likely to be in contact with health services.)
So far so (really very) good. But then the but. The guidelines also recommend testing just about everyone in the areas of the country where more than one in 500 adults is currently known to be infected with HIV (the B section below). This makes very little sense. More importantly, it creates a smokescreen behind which medics can hide. Instead of engaging with their patients, talking to them about their sex lives, assessing their risk behaviour, giving advice about healthy behaviour, they just offer HIV tests to every school teacher in for a hip replacement, every maiden aunt moving to a new job in an area favoured by gay men. You can tell by the wording that some of the people involved in drafting the recommendations were reluctant to impose this unnecessary cost on local health authorities. They should have fought harder to keep it out.
Who should be offered a test?
A. Universal HIV testing is recommended in all of the following settings:
1. GUM or sexual health clinics
2. antenatal services
3. termination of pregnancy services
4. drug dependency programmes
5. healthcare services for those diagnosed with tuberculosis, hepatitis B, hepatitis C and lymphoma.
B. An HIV test should be considered in the following settings where diagnosed HIV prevalence
in the local population (PCT/LA) exceeds 2 in 1000 population (see local PCT data†):
1. all men and women registering in general practice
2. all general medical admissions.
The introduction of universal HIV testing in these settings should be thoroughly evaluated for acceptability and feasibility and the resultant data made available to better inform the ongoing implementation of these guidelines.
C. HIV testing should be also routinely offered and recommended to the following patients:
1. all patients presenting for healthcare where HIV, including primary HIV infection, enters the
differential diagnosis (see table of indicator diseases and section on primary HIV infection)
2. all patients diagnosed with a sexually transmitted infection
3. all sexual partners of men and women known to be HIV positive
4. all men who have disclosed sexual contact with other men
5. all female sexual contacts of men who have sex with men
6. all patients reporting a history of injecting drug use
7. all men and women known to be from a country of high HIV prevalence (>1%*)
8. all men and women who report sexual contact abroad or in the UK with individuals from
countries of high HIV prevalence.